Ethics Question: What age is old enough to donate gametes?

Craig Sweet, MD, a reproductive endocrinologist, recently published a thought provoking article which argues for reducing the minimum recommended age for egg donation from 21 (as ASRM Guidelines recommend) to 18. You can read his entire piece here.

He argues persuasively that women of 18 years (and younger) are able to make decisions about their own health care including difficult decisions about pregnancy, contraception and abortion. At 18, women are able to vote, are able to join the armed forces and are considered financially accountable. The only thing an 18 year old woman can’t do is drink alcohol and donate their eggs.

A dear friend of mine, who is both an IVF lab director and an ethics expert reminded me about pediatric ethics rules: “In the decision-making of pediatric patients, we sometimes follow the 7 year rule. Up to age 7, parental assent and a more paternalistic, yet best interests standard, between 7-14, more direct involvement with the child in decision-making. Keep in mind that some 7-14 year olds undergoing cancer treatments, are very capable of understanding and should absolutely be involved in the decision-making, 14-21 it really depends on the individual, and we should not paint with too wide a brush.” So there are many medical examples in which even very young children are asked to make adult decisions about their healthcare.

Interestingly, Dr. Sweet points out that there appears to be a double standard for egg donors and sperm donors. Most sperm banks will permit sperm donation between 18-19 years of age as the minimum cut-off. Dr. Sweet suspects this apparent gender discrimination may be based on a misplaced cultural stereotype that women have a greater attachment to their offspring than men and thus would be more likely to suffer psychological harm or regret regarding egg donation. in his own words, Dr. Sweet says “I suspect the real concern is that some fear we are taking advantage of a young woman who will have offspring conceived from her eggs and that the potential for psychological damage may be greater for her than a man who donates sperm at the same age.” I don’t disagree with his analysis. Gender stereotypes abound.

Both of my esteemed colleagues suggest that in order to sort out whether a potential donor is “old enough”, it is appropriate to require a consultation between a mental health professional and the potential donor to discuss potential psychological harms. I would agree that requiring a potential donor to meet with a counselor to discuss all the implications of donation prior to donating is a step in the right direction.

Where I differ from my colleagues is that I think age is not the issue at all. It is life experience. Ruth Ragan, an egg donor who wrote about questions arising years after her donation says, “Over the years, thoughts about the happiness, safety and well-being of any donor-conceived children have slowly crept into my head, but it wasn’t until I became a mother that they invaded. Between age 24 and 39 I changed; I became more loyal, more responsible, more patient and less of a risk-taker. I imagine that most anonymous egg donors, young women in their 20s, also change and grow in the years following their donation. Do many of them then look back on their decision to donate, as I do, with worry and ambivalence? My growing concern has developed into an increasingly persistent nagging worry as I search for information about the eggs that I donated and about the retrospective emotions of other anonymous egg donors. It has led me on a journey from altruistic donor to worried former donor.” You can read the entire article here.

In case you think only women feel this way, here is an article from a sperm donor who regrets his donation years later.

This is what concerns me. Both women and men experience huge shifts in their attitudes regarding the meaning of family when they have children of their own. Since most donors are young adults and don’t yet have kids, parenthood is a theoretical abstraction far in the future. I would argue that the only person who can truly understand/assess their own risk of future regret regarding donating their gametes are the potential donors who already have children of their own. Why? Because it is crystal clear to a biological parent what their own sperm or egg can produce. They see the actual living evidence in front of them in their own child. Any gametes donated now would produce half-siblings to this child. If that is where you stand in life, I say “Go for it!” You totally know what you are giving up and what precious gift you have to donate.

Why not just let the mental health professionals sort out these issues and decide whether someone is mature enough to donate gametes as my colleague suggest? Couldn’t one argue that this approach just shifts the paternalism to the mental health expert? Are the mental health experts better able to understand the mind of the donors than the donor themselves? Also, if the mental health professional receives patient referrals from the clinic, doesn’t that create a conflict of interest? The mental health professional who issues more “stop” rather than “go” assessments will likely risk being replaced as too cautious.

So, call my attitude patronizing and “maternalistic” (as opposed to paternalistic) but I can’t quite convince myself that the current system really protects donors against future regret. And yes, I do (perhaps misguidedly) want to protect people from regret (and in worst cases, exploitation) when possible, especially when the consequences of their decisions affect other lives as well as their own.

I would argue that if you really wanted to protect donors from exploitation, only donors with kids should donate gametes. This policy would actually have several advantages to recipients of gametes. First, all donors would be “proven donors’ in the sense that their gametes have been successful in producing a child. Secondly, a more complete medical history exists for older donors. For instance, severe genetic conditions may be revealed in an older donor that the 18 year old donor didn’t know about. You can read about one such example in which a rare cardiac genetic defect was passed on to many donor offspring for years until the donor had his own kids and the disease was diagnosed in himself and his children. Clearly, a more complete donor medical history would have been an advantage for these recipients.

Having discussed advantages, one obvious disadvantage of having older donors is that older egg donors (say 25-35) would have less “fruitful” older eggs relative to the 18 year old donor which makes for a much less attractive donation for the older recipient. However, since under 35 years of age is still considered young in ART terms, most donors with kids would probably fall in this age group and still have adequate egg quality.

I suspect the real non-starter for a policy of requiring donors to already have children would be the likely vast reduction in the number of gamete donors who are still interested in donating once they have a family. Why? Precisely because when they have real children in the world, I would predict, most potential donors (and their partners) are typically less enthusiastic about creating anonymous half-siblings for their children. Real children are much more compelling for inspiring caution than theoretical children. A crash in the number of available donors is something that would not benefit either recipients nor ART providers. In Great Britain, where the law was changed to simply require sperm donors to be known rather than anonymous, sperm donations plummeted dramatically and many Brits found they had to go outside Britain to find sperm donors. But I have to wonder, what does it say about our current framework of gamete donation if we can only readily find donors to donate who are both young and anonymous?

Incidentally, the other major cultural “push back” against gamete donation increasingly comes from donor conceived children. Some of these children regret the nature of their conception because they feel deprived of that biological connection, even in cases where their intended parents truly made them their own children in every way. It may be time to rethink how gamete donation is currently provided and look beyond the immediate needs of conception to consider the long-term best interests of both donors and the children their donations produce.

15 Responses to this entry

I need to sit with the ethical dilemma a little longer before arriving at an opinion. The egg donor that created the donated embryos that we used to conceive was 21 and I shuddered at the idea of someone even that young going through the rigors of a stimulated cycle. And therein is the difference that I see between egg and sperm donation: setting aside whether I think an 18-19 year old boy possesses the maturity to understand the ramifications of his sperm donation, an 18-19 year old boy needs NO medication to ejaculate into a specimen cup. It is something most healthy teen-age boys do regularly. Conversely, to stimulate a female donor, she will require multiple medications AND will have to undergo anesthesia in order for her eggs to be retrieved. The entire process is completely medically involved, requiring multiple visits and multiple medications as well as an invasive procedure.

As usual, your writing is superb and your arguments compelling. I very much appreciated your comments regarding my recent blog.

Your concerns regarding “buyers remorse” by both egg and sperm donors may have merit. I am aware of three articles that cover some of these concerns (Kenney NJ, McGowan ML. Looking back: egg donors’ retrospective evaluations of their motivations, expectations, and experiences during their first donation cycle. Fertil Steril. 2010 Feb;93(2):455-66, Murray C, MacCallum F, Golombok S. Egg donation parents and their children: follow-up at age 12 years. Fertil Steril. 2006 Mar;85(3):610-8, and Purewal S, van den Akker OB. Systematic review of oocyte donation: investigating attitudes, motivations and experiences. Hum Reprod Update. 2009 Sep-Oct;15(5):499-515.) two of which are referenced in the NYTimes Parenting blog you link to in your comments above and your readers may benefit from reviewing these three articles.

There are a few points, however, I feel should be made:
– “Buyers remorse” is a common feeling for so many situations we experience including marriage, divorce, the purchase of a home and even financial investments. In fact, our lives are full of such learning experiences that we could never be fully warned of or fully comprehend even though family, friends and others important to us did their best to educate us.
– We are not necessarily hearing from the thousands of individuals who donated their gametes who are neither studied or vocal about the past donation with their feelings totally unknown to us. While a weaker argument, I feel it needs to be made in light of the “push back” you describe from donor-conceived offspring.

Your idea that we should wait until the potential donor has had a child is intriguing, but as you suggest, not necessarily practical. We also have no proof that these same patients won’t experience the same level of “buyers remorse” we are discussing here. We assume the choice would be more informed because of life’s experiences but I’m not sure this would necessarily be true.

To be honest, I am not even sure we can ever provide complete informed consent regarding the donation of eggs/sperm/embryos as well as so many other issues that enter our lives. I suppose, however, we should do the very best we can. I’m also not sure that mental health professionals will be able to help us counsel the potential donor fully, but it is probably one of the better tools we have available.

The concept of open identity continues to enter the discussions that revolve around egg/sperm/embryo donation procedures. It remains to be seen if this will benefit the donors in the ways we hope could potentially benefit the donor-conceived offspring. Perhaps the availability of such an option would provide solace to the donor knowing they may eventually be contacted by the donor-conceived child. On the other hand, might it also create angst in the years remote from the donation procedure?

Even for the most ethically minded, though, we are probably not in the best position to be unbiased on these subjects as our livelihood, in some part, may depend on the availability of egg/sperm/embryo donors. I agree with you completely that we should be so very careful with our patents so that we do as little harm as possible as we build families that might not otherwise be created.

My goal of writing my blog was was to voice my opinion that there seems to be a gender bias regarding the recommended ages for egg and sperm donation procedures. As a father of two, I somewhat resented the idea that my attachment to my children or children conceived from my gametes would somehow mean less to me than a woman. I suspected that the difference between the recommended ages of donation was currently based a subtle form of gender bias, which may make it more permissible for men to desert their children and families, a trend that has yet to level off. I thought it was time to address this potential self-fulfilling prophecy.

Perhaps it is the concept of the “lessor of two evils” that comes to mind as we sort through the issues balancing the needs of all the parties involved in any donation procedure. I suppose this is why we constantly visit and revisit these issues trying to do what we feel is best for the egg/sperm/embryo donor, the recipient and the donor-conceived offspring we help to create.

Craig,
Thanks so much for coming by and adding your insights and also for providing more references on this topic. You are absolutely correct that this topic is so very layered and complicated–and I did not even mention the physical risks (as was mentioned by another reader and parent of a donor egg-conceived child in other comments here). My good friend Bob (who is the ethics expert I reference above) and I agree on so many things but we had trouble meeting in the middle on this one. He argues fervently for a person’s right to make mistakes or have regrets as you also discuss. I am glad we can discuss this and eventually get closer to “balancing the needs of all the parties involved in any donation procedure”. Hopefully we can meet and discuss this and other topics at ASRM. Best wishes, Carole

Hi It is What it is,
Thanks for your perspective and comments. You are correct that there are vastly different medical risks for egg donors compared to sperm donors. I think that most providers do a good job explaining the physical risks, benefits and alternatives to donors because these are well understood. So I think that even young donors will understand the physical risks and be able to make good choices for themselves regarding those. Trying to anticipate what someone’s emotional reactions will be long term in order to explain their potential psychological risks is much more difficult. Best wishes, Carole

I am becoming more and more convinced that regardless of the differences between what an egg donor endures and what a sperm donor physically experiences both are still sharing their genetics. And the question is: Are 18 – 19 year olds mature enough to think about the long term effects of that? Will they worry later in life that their genetics are out in the world someplace? Now the argument is about life experience? What about life experience? What life experience would you have at the tender age of 18-19 to prepare you for such a big decision.

Dr. Sweet –
With all due respect – there is a HUGE difference between buying a car, a house, getting married, divorce, or financial investments and having a child. Purposely setting out to have a child especially when faced with infertility issues and learning you cannot use your own genetics to have those children you so desperately want.

In fact, having a child through egg donation is probably one of the biggest investments a couple or a single parent is ever ever going to make. This is bringing another life into the world. It’s not something you can trade in, re-sell, remodel, or take a hit on because you made a bad choice in the stock market. So I am sorry you simply cannot compare the two.

Whether we like to address it or not – the truth is we do hear from children created via sperm donation who have emotional issues and are resentful in regards to how they came into the world. If you research the internet you will find that.

Regardless of whether it’s a handful of these kids or the majority of these kids even a small percentage of a child via third party who has emotional issues is a very sad thing and something I feel should not be taken lightly.

The other part to this is that most egg donor kids (from my observation and research) don’t seem to have the emotional issues as the children created via sperm donation. And that I think has to do with the fact that 99% of the children created via egg donation are carried by the mother that’s going to nurture, love, and raise them.

There is still so much we don’t know about donor conceived children through egg donation because they are now just hitting their teen years and I predict in the next ten years we will hear more and I for one will be closely listening as I have an 11 year old via this process and its interesting to me what his thoughts, feelings, and views regarding this are.

Dear Marna,
Thank you for your thoughts. Yes, your concern makes absolute sense. I guess that is the acid test, isn’t it? For me the best donor is one who would still choose to donate eggs after having her own kids. The tricky part is trying to anticipate how the donor will feel when they become parents themselves. As we are discussing this in our household too, my husband asked me –What about people who never want kids of their own but want to donate? My policy would exclude these individuals and that’s not fair. So it is obviously very complicated. I really love hearing everyone’s perspective. Thanks for contributing! Carole

Hi Marna,
I guess perhaps the only relevant life experience might be having kids at 18?–which I am not endorsing as a great idea! All the more reason to raise the donor age for both genders. I saw a video at ASRM once many years ago when one of the big sperm banks rolled out the new idea of video profiles of donors. This young man was talking about why he was donating and the only thing I kept thinking was he had no clue about the implications down the road. He seemed so young and idealistic and without any idea about the gravity of donating his sperm. I would have liked to ask him the same questions now, a decade later and see if he was still so enthusiastic about donation. Please understand that I am not anti-donation–I fully understand what an extraordinary gift it is. I just want, at the very minimum, to be convinced that we are being totally transparent with donors about all the possible psychological risks. Also, if we think that most kids at 18 are not mature enough to have kids because they don’t understand the full ramifications of that choice…are they mature enough to donate their gametes and essentially decide (if donation is anonymous) that kids from that donation will NOT ever be part of their lives? Very very complicated. Carole

Hi I have some questions that I sincerely want answers to because it is hard for me to wrap my head around because I am in contact with people who are not happy about being separated by force or being separated by their own earlier choices and actions and having no way to turn the ship around. I try to avoid the emotional aspect of it because everyone will feel different about it and mostly I like to focus on whether the law is treating people fairly and equally. If the law is treating everyone equally then people can feel one way or the other about all the info there is to have, love it or hate it.

Mama when you ask if they will worry about their genetics ” Will they worry later in life that their genetics are out in the world someplace?” it sounds as if your suggesting they’d be worried about their eggs or sperm or loose genes floating around in a file cabinet somewhere unconnected to anyone or anything. Do you mean you wonder if they worry about their offspring/children/spawn/young out there in the world? Or do you really mean worry about their genetic material?

My own experience is that quite a few come to worry about the health safety and wellfare of the offspring that they opted not to raise. They contemplate the reasons behind their choice when there is no real difference between the offspring they kept and the offspring they allowed someone else to raise such as one deserved their attention more than the others etc. Not all contemplate that. I hope that was not too inflamatory. I tried to stick to facts that could be agreed on by you without saying how anyone will or should feel about any of it.

Hi I have some questions that I sincerely want answers to because it is hard for me to wrap my head around because I am in contact with people who are not happy about being separated by force or being separated by their own earlier choices and actions and having no way to turn the ship around. I try to avoid the emotional aspect of it because everyone will feel different about it and mostly I like to focus on whether the law is treating people fairly and equally. If the law is treating everyone equally then people can feel one way or the other about all the info there is to have, love it or hate it.

Mama when you ask if they will worry about their genetics ” Will they worry later in life that their genetics are out in the world someplace?” it sounds as if your suggesting they’d be worried about their eggs or sperm or loose genes floating around in a file cabinet somewhere unconnected to anyone or anything. Do you mean you wonder if they worry about their offspring/children/spawn/young out there in the world? Or do you really mean worry about their genetic material?

My own experience is that quite a few come to worry about the health safety and wellfare of the offspring that they opted not to raise. They contemplate the reasons behind their choice when there is no real difference between the offspring they kept and the offspring they allowed someone else to raise such as one deserved their attention more than the others etc. Not all contemplate that. I hope that was not too inflamatory. I tried to stick to facts that could be agreed on by you without saying how anyone will or should feel about any of it.

Oops I posted as anonymous by accident. I mean to be myself.
Carole, you said that ‘For me the best donor is one who would still choose to donate eggs after having her own kids. The tricky part is trying to anticipate how the donor will feel when they become parents themselves.”
So are you concerned that you really and truly have the consent of the person before raising that person’s offspring? That is a good and ethical position to take. It is hard though to ever be truly sure that gamete donors consent, or that the genes used to make the embryo going into your body really came from the particular person you chose even if that person did truly give their consent.
One of the points I often raise is that its probably difficult for people working in these clinics to keep track of whose eggs and sperm and embryo’s belong to whom. I’m pretty sure they all look alike to the naked eye and so errors happen frequently enough to where it should be a concern, especially for patients who never signed forms consenting to donate. There have also been quite a few unscrupulous individuals at some major university clinics and donation agencies that realize its impossible to tell one egg from another and that a person has to trust the clinic when they are told that only 8 eggs were harvested when in fact the number is much higher than that. UC Irvine is a good example of people consenting to donate, for reproductive purposes, but not consenting to allow anyone to carry and deliver their offspring for them and not consenting to have someone else raise their offspring, yet, because the papers are not filed in court and the law does not handle the transfer of parental obligations after birth like adoption, those people lost their offspring. Recipients of the misappropriated gametes may have cared that those people wanted their offspring back or may have felt they wanted a donor’s offspring and are unconcerned about the consent not being given.

One very broken part of the gamete donation process is that recipients are entitled to keep or claim offspring of people that did not give their consent, often even when error is discovered and there seems to be no formal way of ensuring that children who are donor offspring are genuinely the offspring of a given donor and that the given donor did give their consent not just to donate, but to reproduce and gave consent to gestation outside their body and then lastly gave their consent to allow her offspring to be raised by someone other than herself and the genetic father. The gamete donation in and of itself is not necessarily consent to all the other stuff because women do donate for research unrelated to reproduction and some might agree to have their egg fertilized for research only but not agree to allow someone to gestate or keep their offspring. The agreements you cited in your most recent post are great. They describe the donor as giving up her offspring to be raised by others should any be born of her donated genetic material or donated embryo. People alway say I confuse eggs with kids but the agreement demonstrates that the consent is given to allow the child to be raised by others and that is entirely separate from the act of donating the egg itself.

I’m glad people want to be sure of consent. The best way to do this is in a formal adoption proceeding because the process is overseen by a supposedly disinterested 3rd party judge that works for the state. The docotor or clinic that keeps these agreements privately on file has a financial interest in the process and so the other players are not as well protected from fraud, error, graft. Why do you think there is a push for openness in gamete donation similar to adoption and not a documentation process similar to adoption when there is so much benefit to it? Like if you were concerned about being sure the donor gave her consent knowing who she was would help a lot. Seeing her signature in blue ink might make you sleep better.

Hi Marilynn,
No, I am not concerned about the consent process for gamete donation in general. I think (and of course there are always exceptions in human behavior) but I think most clinics/agencies/doctors use a consent process which discusses risks, benefits and alternatives, mostly to the physical issues but also to the emotional issues. No clinic/agency or doctor benefits when patients have regrets or feel that they were poorly informed. They tend to sue and complain loudly.

I would give most programs the benefit of the doubt that they are trying to do the right thing for the right reasons. Re: keeping track of gametes in the lab, good programs have detailed chain of custody protocols and this is THE most important work of the day, more important than ensuring pregnancies occur. Here’s more information on that from a previous post http://fertilitylabinsider.com/2010/05/lab-mistakes/

If you want to look at financial motive, a good clinic with happy clients/patients will grow faster and make more money than one that takes shortcuts that hurt clients/patients because the second one will eventually be found out and suffer the consequences.

I think that perhaps the standard consent process could be updated regarding the potential emotional effects based on new evidence. I also know that people can be given all the relevant information up front, even an excess of information, and still make a choice that down the road, they regret. I think the bigger problem is that few of us will accurately predict the emotional needs of children not yet born and even the donors and recipients may come to regret that they closed the doorway between the child and donor at the very beginning. A more flexible policy that allows a second option to know each other would be beneficial to many involved in this process down the road. And this should be an option to reconnect, not a requirement. My two cents. Carole